Health and Dental History

 

Please complete the form below

Name *
Name
Phone *
Phone
Allergies
Endocrine
Cardiovascular
Respiratory
Neurological
Musculoskeletal
Social Habits
Infectious Diseases
I am currently satisfied with the appearance of my smile.
When I visit the dentist, I tend to become anxious/nervous.
I usually clean or brush my teeth twice a day.